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The Challenge of Preventing AIDS

Author: Toni Johnson
December 28, 2007

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The man just chosen to head (Independent) South Africa’s leading political party, Jacob Zuma, had rape charges dismissed last year. But he did admit having unprotected sex with the woman involved, though he knew she had HIV. According to Zuma, the woman indicated “she wanted sex” (CSMonitor) by wearing a skirt and he protected himself by showering. The incident reflects the difficulty of controlling the disease in sub-Saharan Africa, where sexual violence runs rampant, and multiple partners are the norm. It also indicates the all-too-common unscientific views held in the region about the spread of HIV/AIDS.

For years, health groups tried to educate people throughout sub-Saharan Africaabout the role of condoms for protection. Now, a controversial U.S. debate over prevention methods has spilled into Africa, pitting social conservatives who seek to promote abstinence against many health experts who say condoms combined with education is best. In 2003, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) pledged $15 billion over five years focusing on fifteen nations, most of them in Africa. The money comes with conditions: A third of funds must go to abstinence and monogamy education; promotion of condom use is restricted to “high-risk” adults; and the groups receiving funding must vow to end prostitution. With the program up for renewal by Congress (CQ) in 2008, a number of health advocates hope to remove these restrictions.

The Bush administration says more than forty million people were reached with pro-abstinence and monogamy activities by 2006. Another twenty million “high-risk” adults were reached with an initiative promoting condoms. But that same year, a report by the nonpartisan Government Accountability Office (GAO) criticized the administration’s handling of PEPFAR, saying administration officials required spending more (PDF) on abstinence education than the law mandated. A 2007 report published by the U.S. National Academies of Sciences says a lack of information makes it difficult to evaluate the efficacy of the abstinence programs.

But for some women in the developing world, abstinence is not up to them. Some turn to sex for survival, and others are coerced into sex or raped, even in marriage, reports U.S.-based government watchdog the Center for Public Integrity. In attempts to debunk abstinence-until-marriage arguments, some critics point to studies and statistics (PDF) that show infections rising in married women, sometimes at a greater rate than infections of sexually active single women. One advocate says wives in some AIDS-afflicted states in Africa “suffer violence” (WashPost) if they ask for faithfulness or attempt to abstain. On the other hand, the head of a relief group receiving PEPFAR money told the U.S. Senate Foreign Relations Committee recently that “condoms alone are insufficient for a generalized epidemic.” CFR global health expert Laurie Garrett says designing foreign policy “to stamp out sexual activity among consenting adults is a fool’s errand.”

Most of the money from PEPFAR is spent on providing antiretroviral treatments to focus countries. Funds are also spent on programs to help change the behavior (PDF) of men and boys as well as improving gender equality. At the end of September 2007, the program had provided more than 1.4 million people with antiretroviral treatments, lauded by many health experts. But even those efforts have come under fire. The Bush administration decided to limit the acquisition of generic drugs to ones approved in the United States, which it argues is necessary to keep treatments safe and effective. But critics contend the move raises the cost and lowers the number of people reached.

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